osteoporosis 9 th january 2013 dr julian tomkinson
TRANSCRIPT
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Osteoporosis9th January 2013
Dr Julian Tomkinson
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RCGP Curriculum
3.06 Women’s Health
‘Be able to advise on prevention strategies relevant to women’
3.20 Care of People with
Musculoskeletal Problems‘Awareness treatment of fragility fracture in osteoporosis’
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NICE
Direct medical costs of fragility fractures to the UK healthcare economy estimated at £1.8 billion in 2000, with the potential to increase to £2.2 billion by 2025
Most of these costs relating to hip fracture care
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QOF 2012
Producing a register of patients (a) aged 50-74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; or (b) aged 75 years and over with a record of a fragility fracture after 1 April 2012
Ensuring that patients on the register who are aged between 50 and 74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, are treated with an appropriate bone-sparing agent
Ensuring that patients aged 75 years and over with a fragility fracture are treated with an appropriate bone-sparing agent.
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Statistics
Approximately 14,000 people die per year from osteoporosis (greater than carcinoma of ovary, uterus and cervix put together)
Patients who sustain a vertebral fracture consult their GP, on average, 14 extra times in the year following it.
The mortality of hip fracture in older patients is 20% at three months
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Osteoporosis (‘porous bones’)
‘a progressive systemic skeletal disease characterised by reduced bone mass/density and micro-architectural deterioration of bone tissue’
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Osteoporotic (Fragility) Fracture
• Fractures that result from mechanical forces that would not ordinarily result in fracture (fracture caused by a force equivalent to the force of a fall from a standing height or less)
• Defined as fractures associated with low bone mineral density. Can affect spine, forearm, hip and shoulder fractures
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Osteoporosis: hip BMD 2.5 SD or more below the young adult reference mean (T-score ≤-2.5)
Severe osteoporosis:T-score ≤-2.5 PLUS fracture
Low bone mass (osteopenia):T-score less than -1 but above -2.5
Normal:T-score ≥-1
Bone Mineral Density (BMD)
WHO / IOF standards
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Prevalence
• Prevalence of osteoporosis increases markedly with age
(2% at 50 years to more than 25% at 80 years in women)
• NICE estimates there are 2 million women who have osteoporosis in England and Wales
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Risk Factors for fragility fracture
• Age
• Low BMD
• Parental history of hip fracture.
• Alcohol intake of four or more units per day.
• Rheumatoid arthritis.
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Risk factors for reduced BMD
Female gender
Corticosteroid therapy or Cushing's syndrome
Ankylosing spondylitis
Crohn's disease
Untreated premature menopause (<45 years) or prolonged secondary amenorrhoea
Low body mass (<19 kg/m2) and anorexia nervosa
Poor diet (particularly if calcium-deficient)
Malabsorption syndromes, eg coeliac disease.
Post breast cancer treatment
Prolonged immobilisation or a very sedentary lifestyle
Smoking
Primary hypogonadism (men and women)
Primary hyperparathyroidismHyperthyroidism
Osteogenesis imperfecta
Caucasian or Asian origin
Post transplantation
Chronic renal failure
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Presentation
• Fracture – still need to be aware of and recognise fragility fractures
• Case finding
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Case finding If a fragility fracture occurs this should trigger bone
density measurement (although in women aged ≥75 years osteoporosis can be assumed and first-line treatment initiated (alendronate) without (DEXA) scan if the clinician feels this is appropriate).
Patients with any risk factors above should be considered for DEXA scanning, particularly if there are one or more risk factors for fractures (family history, increased alcohol intake or rheumatoid arthritis).
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Fracture risk calculators
WHO risk calculator available (FRAX®) which calculates the ten-year probability of a major osteoporotic fracture
For UK populations, the recent QFracture® score may be more appropriate for fracture risk assessment
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Case study
66 year old lady presents concerned about the risk of her having osteoporosis:
Mother of patient fell age 69 and fractured hip and died of complications of surgery (DVT and PE)
Well lady with no significant past history documented
Occasional backache
Thinks may have lost 2cm in height.
Drinks 2 large glasses of wine per day
Calculated height 165cm weight 65kg = BMI 24.2
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Diagnosis of osteoporosis centres on the assessment of BMD
DEXA is regarded as the gold standard technique for diagnosis; the accuracy at the hip exceeds
90%
Residual errors arise for various reasons
Incorrect diagnosis of osteoporosis can be caused by osteomalacia, osteoarthritis or soft-tissue calcification
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Referred for DEXA SCAN
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Case continued
Scan shows T score -2.3 hip and -2.5 spine
Wedge fracture seen at T10
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Other investigations
Consider the following screening blood tests, in patients suffering from osteoporosis, to identify treatable underlying causes:FBC and ESR,U&E, LFTs, TFTs, serum calcium, ALP
Testosterone/gonadotrophins in men.Serum immunoglobulins and paraproteins,
urinary Bence-Jones' proteins.
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Management
Treatment for osteoporosis should include not only drug treatment but also advice on:
Lifestyle
Nutrition
Exercise
measures to reduce falls
Ensure adequate calcium intake and vitamin D status, prescribing supplements if required.
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Management
Patients with osteoporosis (T-score -2.5 or worse) at any age:
Consider hip protectors and assessment of ongoing risk of falls.
Reduce polypharmacy, especially sedatives.
Ensure adequate calcium (0.5-1 g) and vitamin D (800 IU) - supplementation may be necessary.
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Secondary prevention - T-score treatment threshold for second-line treatment in patients with previous fragility fracture[1]
Age If T-score not available
When alendronate not an option, treat with risedronate or etidronate at these
values or worse[3]
Risk factors = family history, alcohol >3 units/day or rheumatoid arthritis
No fracture risk factors
1 fracture risk factor
2 fracture risk factors
50-54 Refer for DEXA Not recommended -3.0 -2.5
55-59 Refer for DEXA -3.0 -3.0 -2.5
60-64 Refer for DEXA -3.0 -3.0 -2.5
65-69 Refer for DEXA -3.0 -2.5 -2.5
70-74 Refer for DEXA -2.5 -2.5 -2.5
75 and over
DEXA may not be required
(see any local guidelines)
-2.5 -2.5 -2.5
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Primary prevention - T-score treatment threshold for second-line treatment in patients without previous fragility fracture[3]
Age If T-score not available
When alendronate not an option, treat with risedronate or etidronate at these values or
worse[3]
Risk factors = family history, alcohol >3 units/day or rheumatoid arthritis
No fracture risk factors
1 fracture risk factor
2 fracture risk factors
65-69 Refer for DEXA Not recommended -3.5 -3.0
70-74 Refer for DEXA -3.5 -3.0 -2.5
75 or older
Refer for DEXA unless over 75
and 2 risk factors
-3.0 -3.0 -2.5
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Calcium & Vitamin D
Examples:
Adcal-D3®, Adcal-D3® DissolveCacit D3®Calceos®Calcichew D3®, Calcichew D3 Forte®Calfovit D3®Kalcipos-D®Natecal D3®Sandocal®
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BisphosphonatesExamples:AlendronateRisedronateEtidronateIbandronatePamidronateZoledronate
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Fracture classWomen with
existing vertebral fracture
Women without vertebral fracture and T score <−2.5
Any radiologic vertebral 8 29
Any clinical 13 11
Any nonvertebral 21 12
Hip 46 66
Numbers Needed To Treat (NNT)
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How to take bisphosphonates
‘You need to swallow the tablet with a full glass of water and sit upright for 30 minutes afterwards. This is because bisphosphonates can irritate your oesophagus’
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Treatment holidays
Stop after 3-5 years?
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Safety Issues
Osteonecrosis of the jaw
rare with oral bisphosphonates good oral hygiene should be
encouraged
Atypical femoral fractures
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Safety Issues
There may be a small increased risk in oesophageal cancer in individuals
taking bisphosphonates
(NNH 1000 over 5 years)
(Importance of emphasising the correct way to take these tablets and encourage early reporting of adverse effects)
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Safety Issues
Calcium supplementation alone slightly increases the risk of non-fatal
myocardial infarction but has no effect on stroke or mortality. This study is not
applicable to combined calcium and vitamin D supplements.
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Other Medications:
Strontium (dual action bone agent DABA)
Raloxifene (selective estrogen receptor modulator (SERM)
Teriparatide (recombinant PTH)
Denosumab (monoclonal antibody)
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Possible other benefits
Bisphosphonates may have anti-cancer properties, particularly reducing the incidence
of post-menopausal breast cancer
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1. Letter comes into docman:
Mrs Nora Olivia Fletcher age 77 Admitted: Orthopaedics via A&E Diagnosis: Sub-capital fracture of left hip Treatment: Thompson’s hemi-arthroplasty left hip Complications: Developed pneumonia post operatively.
Treated with IV antibiotics and improved
Discharge: To intermediate care Medication: Bisoprolol 2.5mg daily Aspirin 75mg daily Atrorvastatin 10mg daily Ramipril 5mg daily Prednisolone 7.5 mg daily Nitrolingual spray as needed
Case 2
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Previous history from notes: Problems Polymyalgia rheumatic 2013 Angina 2006 Cholecystectomy 2000 Current medication Bisoprolol 2.5mg daily Aspirin 75mg daily Atrorvastatin 10mg daily Ramipril 5mg daily Prednisolone 7.5 mg daily Nitrolingual spray as needed Allergies Penicillin – severe rash Other Weight 60kg Height 165cm BMI 22.0 Ex-smoker – cigarettes stopped 2006 Alcohol 24 units per week 2006
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Frax calculation
Frax calculation
10 year probability of fracture
Major osteoporotic 31%
Hip Fracture 18%
Suggests refer for Dexa scan
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Case 4
67 year old lady with hx of COPD sent by colleague for dexa scan. Never had fracture but had aches and pains and had several courses of steroids and antibiotics over winter and spring
Scan shows osteoporosis in neck of femur and in spine
Medication: salbutamol 2 puffs prn salmeterol 2 puffs bd, tiotropium one capsule inhaled daily. Citalopram 20mg daily.
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Case 3
45 year old lady presents to surgery
No health issues, exercises 4 x per week, zumba and spin classes. Healthy diet, never smoked, minimal alcohol. Regular periods. No significant past medical problems.
Concerned as step mum recently suffered back pain and was found to have a compression fracture at T8. She has read about dexa scanning and has come to request one
BMI 22.9
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References
http://www.shef.ac.uk/FRAX/ (FRAX)
http://www.qfracture.org/ (QFRACTURE)
http://www.patient.co.uk/doctor/osteoporosis
http://www.sign.ac.uk/pdf/qrg71.pdf (SIGN GUIDE)
http://www.nice.org.uk/guidance/ (NICE GUIDE)
http://www.nos.org.uk/ (Osteoporosis Society)
Fracture Risk Reduction with Alendronate in Women with Osteoporosis: The Fracture Intervention Trial http://jcem.endojournals.org/content/85/11/4118.full